Deficiencies (last 5 years)
Deficiencies (over 5 years)
5.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
22% better than Oregon average
Oregon average: 6.7 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Capacity: 59
Deficiencies: 3
Nov 6, 2025
Visit Reason
Facility failed to ensure a safe medication system and adequate professional oversight. Multiple discrepancies in narcotic tracking logs and medication administration records placed residents at risk. Immediate risk addressed but overall system failures remain.
Findings
Facility failed to ensure a safe medication system and adequate professional oversight. Multiple discrepancies in narcotic tracking logs and medication administration records placed residents at risk. Immediate risk addressed but overall system failures remain.
Deficiencies (3)
| Description |
|---|
| OAR 411-054-0055 (1)(a) Systems: Medications and Treatments (1) MEDICATION AND TREATMENT ADMINISTRATION SYSTEMS. The facility must have safe medication and treatment administration systems in place that are approved by a pharmacist consultant, registered nurse, or physician.(a) The administrator is responsible for ensuring adequate professional oversight of the medication and treatment administration system. |
| OAR 411-054-0055 (1)(e) Systems: Tracking Control Substances (e) The facility must have a system approved by a pharmacist consultant or registered nurse for tracking controlled substances and for disposal of all unused, outdated or discontinued medications administered by the facility. |
| OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. |
Inspection Report
Capacity: 59
Deficiencies: 3
Feb 22, 2024
Visit Reason
Kitchen inspection revealed multiple sanitation issues including buildup of debris, undated food items, improper food storage, and equipment issues. Some deficiencies corrected by revisit.
Findings
Kitchen inspection revealed multiple sanitation issues including buildup of debris, undated food items, improper food storage, and equipment issues. Some deficiencies corrected by revisit.
Deficiencies (3)
| Description |
|---|
| OAR 333-150-000 Food Sanitation Rule - Resident Services Meals |
| OAR 411-054-0030 Resident Services Meals |
| OAR 411-054-0030 Resident Services Meals |
Inspection Report
Complaint Investigation
Capacity: 59
Deficiencies: 2
Feb 1, 2024
Visit Reason
Investigation found failure to carry out medication and treatment orders as prescribed for multiple residents. Medication errors reported to APS and staff trained.
Findings
Investigation found failure to carry out medication and treatment orders as prescribed for multiple residents. Medication errors reported to APS and staff trained.
Deficiencies (2)
| Description |
|---|
| OAR 411-054-0055 Systems: Treatment Orders |
| OAR 411-054-0055 Systems: Treatment Orders |
Inspection Report
Complaint Investigation
Capacity: 59
Deficiencies: 2
Sep 27, 2023
Visit Reason
Facility failed to fully implement an Acuity-Based Staffing Tool for sampled residents. Projected date of compliance unknown.
Findings
Facility failed to fully implement an Acuity-Based Staffing Tool for sampled residents. Projected date of compliance unknown.
Deficiencies (2)
| Description |
|---|
| OAR 411-054-0055 Licensing Complaint Investigation |
| OAR 411-054-0200 Acuity-Based Staffing Tool |
Inspection Report
Capacity: 59
Deficiencies: 14
Jun 6, 2022
Visit Reason
Re-licensure survey with multiple deficiencies including food sanitation, service planning, change of condition monitoring, coordination of care, psychotropic medication use, and compliance with health care rules. Some deficiencies corrected on revisits, others remained not corrected. Repeat citations noted.
Findings
Re-licensure survey with multiple deficiencies including food sanitation, service planning, change of condition monitoring, coordination of care, psychotropic medication use, and compliance with health care rules. Some deficiencies corrected on revisits, others remained not corrected. Repeat citations noted.
Deficiencies (14)
| Description |
|---|
| OAR 333-150-000 Food Sanitation Rule - Resident Services Meals |
| OAR 411-054-0200 Resident Services Meals, Food Sanitation Rule |
| OAR 411-054-0260 Service Plan: General |
| OAR 411-054-0270 Change of Condition and Monitoring |
| OAR 411-054-0280 Resident Health Services |
| OAR 411-054-0290 Res Hlth Srvc: On- and Off-Site Health Srvc |
| OAR 411-054-0303 Systems: Treatment Orders |
| OAR 411-054-0330 Systems: Psychotropic Medication |
| OAR 411-054-0455 Inspections and Investigation: Insp Interval |
| OAR 411-054-0142 Administration Compliance |
| OAR 411-054-0162 Compliance With Rules Health Care |
| OAR 411-054-0163 Nutrition and Hydration |
| OAR 411-054-0164 Activities |
| OAR 411-054-0165 Behavior |
Inspection Report
Complaint Investigation
Capacity: 59
Deficiencies: 1
Jul 7, 2021
Visit Reason
Unannounced complaint investigation found no deficiencies related to the complaint.
Findings
Unannounced complaint investigation found no deficiencies related to the complaint.
Deficiencies (1)
| Description |
|---|
| OAR 411-054-0010 Licensing Complaint Investigation |
Inspection Report
Complaint Investigation
Capacity: 59
Deficiencies: 1
Jul 7, 2021
Visit Reason
Unannounced complaint investigation found no deficiencies related to the complaint.
Findings
Unannounced complaint investigation found no deficiencies related to the complaint.
Deficiencies (1)
| Description |
|---|
| OAR 411-054-0010 Licensing Complaint Investigation |
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